THE STAR-TRIBUNE, Minneapolis, Minnesota, Tuesday, August 15, 2006.

Why circumcise?

Cultural preference, not medicine, drives the decision of whether or not to circumcise baby boys. And mostly that depends on your religion and where you live.

Josephine Marcotty, Star Tribune
Melissa King

Many of Sara Stephenson's friends are taken aback when she tells them that her son will not be circumcised after his birth next month. Some have reminded her of an episode in the TV series "Sex and the City" in which the female characters are repulsed by the thought of having sex with an uncircumcised man.

She wouldn't want that to happen to her son, would she?

"I tell them it's just a TV show," said Stephenson, 34, of Chaska.

Still, this is just one of the many issues that parents struggle with when they face the decision of whether to circumcise their sons. Yes, there are some minor health aspects to the decision, but experts say there is no clear medical reason to remove the foreskin of an infant's penis. The choice is largely driven by cultural preference.

In the United States, most boy babies are circumcised because most American men are. That, and the fact that circumcision is usually paid for by health insurance, is why the practice continues, said Eli Coleman, a professor and director of the Program on Human Sexuality at the University of Minnesota.

"We are all trying to look like a man ... is supposed to," he said.

That's also why leaving their son uncircumcised is a natural choice for Stephenson and her husband, Paul, 30. They're British. And in Great Britain, with the exception of Jewish and Muslim religious practices, boys aren't routinely circumcised. They haven't been since the early 1950s, when the National Health Service stopped paying for it.

"The treatment is cosmetic and totally unnecessary," said Paul Stephenson.

This year the state of Minnesota stopped covering routine circumcisions for the 670,000 low-income Minnesotans covered by taxpayer-funded health plans. Before that, about 10,000 baby boys were circumcised annually at an average cost of $54 each.

But that change in circumcision policy has prompted many physicians to predict that private insurance won't be far behind. Most private plans still cover routine circumcision and have no plans to change, said health plan officials. But "the writing is on the wall," said Dr. John O'Connell, a pediatrician who practices at clinics in Edina, Burnsville and Shakopee.

"We are concerned that this is not going to be covered by commercial insurers as time goes on," said Dr. Peter Dehnel, medical director for the Children's Physician Network, a statewide organization of pediatric clinics.

So some clinics are preparing to do circumcisions in the doctor's office, as opposed to hospital nurseries. O'Connell said his clinics are planning to charge $300. That way, parents who want the procedure but don't have coverage will pay much less than it would cost in the hospital, he said. Rates for circumcision vary, hospital officials said, but would most likely cost $700 or more if done in a hospital.

"That health plan thing is shocking to me," said Lee Anne Swanson-Peet, 35, of St. Paul, who was attending a recent prenatal class with the Stephensons at Abbott Northwestern Hospital in Minneapolis. O'Connell, who gave a talk about infants during the class, warned the group to check with their health plans to make sure circumcision is covered.

Swanson-Peet said that if she has a boy he will be circumcised, partly because she is Jewish. "But I would do it anyway," she said, because she wants him to look like his father, and because it's the norm in the United States.

It's unclear if dropping circumcision from insurance coverage would have an effect on its frequency. HealthPartners tried that for a while in the mid-1980s, and finally gave in to public and medical pressure and started covering it again in the mid-1990s, said Dr. George Isham, medical director of HealthPartners.

"That decision was based on the notion that this was a patient dis-satisfier, and there was not a clear consensus in the medical profession," he said.

It is, nonetheless, one of the few cosmetic procedures that insurance does cover routinely, Isham said. The only other one he could think of, he said, was breast reconstruction after cancer surgery.

Although no one knows its origin, circumcision has been around for thousands of years in many cultures. Egyptian mummies have been found to be circumcised, and wall paintings from that era depict ritual circumcisions. It is an ancient ritual in both Muslim and Jewish religions, but not generally associated with Christian or Eastern religions.

Belief in its health benefits arose in the 19th century. Doctors advised using circumcision as a treatment for practices that were considered sexual problems, such as masturbation. During World War II, U.S. military personnel were circumcised as a way of reducing sexually transmitted diseases.

In the mid-1970s, an estimated 80 percent of boys were circumcised nationwide, but the number declined in subsequent decades.

Rates are climbing again

Now, the number appears to be rising again. An analysis of inpatient hospital data published in the Journal of Urology in 2005 showed that nationwide rates climbed from 48 percent between 1988 and 1991 to 61 percent by 2000.

But those percentages varied widely by geography. It was highest in the Midwest and Northeast -- averaging 71 percent and 68.9 percent respectively, and lowest in the West -- 28 percent. Most of the increase occurred in the South, which averaged 53 percent, said Dr. Caleb Nelson, lead author of the study and a pediatric urologist at Children's Hospital in Boston. The research does not explain why those changes occurred, he said, but it may be linked to a population shift from North to South during that period.

The Centers for Disease Control and Prevention estimates that in 1999 the national average rate was 65 percent.

[CIRP Note: In 2004, the average rate of non-therapeutic circumcision of newborn boys in the United States was 55% and in a declining trend, according to the National Inpatient Sample. This is the lowest rate since approximately 1935.]

The practice persists despite the fact that leading medical organizations have said there is no clear medical benefit. And although circumcision used to be done without local anesthesia, that's no longer the case. With anesthesia, doctors say that most babies appear to feel little discomfort.

It has, however, always been a contentious procedure in medicine. And in 1999 the American Academy of Pediatrics adopted a hands-off policy. It says that doctors should provide parents with the medical pros and cons -- and then let them decide.

"This is the perfect situation where you ought to let people choose," said Isham.

And most parents choose circumcision because they want their sons to look like their fathers, or because they are worried that their sons might look different than other boys, doctors say.

"It's not what the girls think, it's what the boys will think," said Coleman. "It's that father and son will go into the shower and be comparing their penises, that this is what a good man looks like."

Some parents find that ridiculous.

"I remember telling one of my friends, 'If your husband had blue eyes and your son had brown, would you give him contacts?' "said Michelle Cunningham, 45, of Minneapolis, who has two sons. "Why do their penises have to match?"

Josephine Marcotty • 612 673 7394

(File created 16 August 2006)